Consensus Principles for Health Care Delivery
TABLE OF CONTENTS Consensus Principle for Healthcare Delivery... 3 Responsibilities of Various Parties to the Health Care System... 4 Individuals and Families... 4 Employers... 5 Providers... 6 Government... 7 Community... 8 Insurer and Third-Party Payer... 9 Consensus Principles for Health Care Delivery Task Force... 11
CONSENSUS PRINCIPLES FOR HEALTH CARE DELIVERY There are fundamental questions which must be considered in the development of proper public policy regarding health care delivery. As a responsible business organization, the Grand Rapids Area Chamber of Commerce has considered the following questions and adopts the following principles. WHO IS RESPONSIBLE FOR AN INDIVIDUAL S HEALTH CARE? Each person is primarily responsible for his or her own health care. It is the mutual responsibility of the individual, health care providers, employers, third party payers, government and community to play appropriate roles in the delivery of health care, but recognizing that there are treatments and procedures which cannot be made available to all individuals. The role of each party in the delivery of proper health care to individuals is described in this policy statement. WHAT SHOULD DETERMINE THE LEVEL OF BASIC HEALTH CARE? Health care is not an unlimited entitlement. Basic health care is less than the full range of treatment options generally available. The definition of the specifics of basic health care is the responsibility of society. Society must prioritize the range of all health care services and procedures, and allocate limited government and health care resources to make what is defined as basic health care available. The proportion of our federal or state resources allocated to basic health care must be established by our elected representatives if government is expected to pay for the care of those who cannot pay for it with personal or insurance resources. WHAT IS THE APPROPIATE EXPENDITURE LEVEL FOR HEALTH CARE? Health care consumes an increasing, and alarming, proportion of the nation s resources. Continued escalation of the proportion of the nation s resources for health care cannot continue at the current pace without severe threats to the economy. Limits on health care spending are essential. Therefore, it is essential for all those involved to consider cost/benefit factors when making all treatment decisions. There are limited resources available. Less expensive, but reasonably effective, alternatives should be used whenever available. 3
RESPONSIBILITIES OF VARIOUS PARTIES TO THE HEALTH CARE SYSTEM Solutions to the health care problems of the country require collaboration and cooperation by all parties as partners who must be willing to examine their roles and responsibilities. Everyone must continuously challenge their basic assumptions if the problems are to be solved. There are six principal players in the health care process. The responsibilities of each are described as follows: 1. Responsibilities of Individuals and Families Background It is well known that many of the diseases commonly treated within our health care system are preventable, not by vaccine or medication, but by each individual s behavior throughout life. An individual s risk of developing conditions such as cardiac disease, hypertension, and diabetes is directly related to that individual s choices related to diet, exercise and tobacco. Given the significant influence that individual behavior has in prevention and treatment of disease, it is necessary to include the role of human behavior in any discussion of health care delivery, benefits or funding. a) Individuals have the responsibility of paying a significant co-payment and deductible for health services other than those services focused on prevention. They should expect to share in the cost of insurance premiums as well. Payment for premiums or services is essential in educating users of the cost of services, thereby helping to control utilization, as well as generating necessary funds for health care. b) A person s choices (e.g. diet, exercise, smoking, alcohol and substance abuse) are factors which directly affect the utilization and cost of scarce health care resources. This is true regardless of who pays for the services. Individuals should take a responsibility for their own personal health care choices and an active role in properly managing any chronic illnesses. Each individual is responsible for becoming well informed about how to maintain his/her own health and well being, and about how to utilize limited health care resources effectively and efficiently. c) Individuals should be encouraged to use patient advance directives, sometimes known as living wills, defining the scope and limits of health care they desire when unable to direct their own care. This includes a durable medical power of attorney to instruct families and health care providers regarding the type of health care desired under those circumstances. Individuals should provide copies of these documents to their physicians and other health care providers. d) Individuals have a responsibility to seek and accept effective but less expensive treatment techniques and devices even though a third party payer is paying for them. This includes encouragement of a treating physician in efforts for cost containment. Individuals must be discriminating 4
users of health care services regardless of who pays for the services. e) In the interest of preventing avoidable complications and cost, where the individual s employer s health plan includes a medical savings account or a plan of the type allowed under Section 125 of the Internal Revenue Code (a pretax dollar account to be used for health care), the individual has a responsibility to balance the short term benefit of saving the money against the long term consequences of choosing not to treat a particular medical condition. This same balancing process (short-term benefit against the long-term consequences of not treating) must always be considered, regardless of who pays for the treatment. f) In order to appropriately spread risk and help keep health insurance affordable, it is incumbent upon everyone to purchase health insurance coverage. 2. Responsibilities of Employers Background In the current U.S. health care environment, it is expected that employers are the sponsors of health coverage for most working persons. This is a relatively recent idea, growing out of the wage controls of World War II. The current income tax laws also promote this since the employee can receive health insurance as a tax-free benefit. a) There may be good reasons to re-evaluate the role of the parties, with the employee taking more responsibility for purchasing the coverage. However, where the employer is the sponsor of the plan, the employer should pay some of the cost of the premiums for the plan for regular employees who work more than half time. b) Employer-sponsored plans should also make dependent coverage available for those employees who select it with the premium costs shared by the employer and employee. c) Tax deferred health care savings programs, such as a Section 125, Medical Savings Account, Health Reimbursement Account or Health Savings Accounts, are available for working individuals. These accounts can supplement other plans or serve as a means to pay for health benefits. Employers should sponsor such plans so employees can utilize tax deferred health care dollars as effectively as possible. Plans should be offered in conjunction with an educational program for employees to fully understand the benefits of participating. d) Group plans offer reduced costs, as compared with individual health insurance, so employers should use group purchasing power to improve access to affordable coverage for employees. 3
e) Group plans should be able to reflect employees choices (e.g. diet, exercise, smoking, alcohol and substance abuse) in benefit design and premiums costs. f) Employers should encourage reduction of health risks among its employees such as smoking cessation, wellness programs, and nutrition information, and facilitate access to such programs. g) Employers should educate their employees on proper utilization of their health plan to increase the likelihood of cost reduction and better care. 3. Responsibilities of Providers Background Over the last decade, the quality and availability of clinical and practice management information has greatly increased for providers through advances in electronic and communication technology. Increased availability of clinical practice guidelines, evidence-based outcome studies, and disease management technology has shown to improve health outcomes when incorporated into provider practices. Additionally, the last decade has seen growth in provider alliances in the form of risk groups, physician organizations, and physician-hospital organizations. These groups have formed, in part, due to the increasing financial and administrative complexity of health care. Both of these broad changes in technology and provider alliances call for support of the following consensus principles: a) Providers should provide access to basic health care for all people. b) Providers should communicate promptly with each other to coordinate care of patients as allowed by federal and state regulations. Information systems should be accessible and allow easy exchange of data in a confidential and responsible manner. c) The introduction of new technologies, pharmaceuticals, and therapies should be done with a broad-based analysis of the cost benefit ratios. Evidence based medicine, including retrospective evaluation, should be used to help decide which technologies, pharmaceuticals, and therapies should be used. d) Treatment should include a holistic approach of physical, behavioral, and spiritual considerations. e) Providers are encouraged to make sure patient s advance directives are identified and utilized. 6
f) Providers should make prevention of disease a priority. Providers should encourage patients to take an active role in their personal health care through comprehensive programs aimed at education and individual responsibility. Programs that improve diets, stress, exercise, and reduce smoking and hypertension should be encouraged. g) Providers should be aware of the critical role substance abuse and mental health conditions play in the onset, course and outcomes of many chronic medical conditions. h) Providers have a responsibility to provide quality services in the most cost-effective manner consistent with the best interest and convenience of the patient. i) Providers should develop a unified, common, community-wide, electronic medical record. 4. Responsibilities of Government Background The government has several points of influence in the health care system, including legal and regulatory authority, tax related controls, and serving as the safety net payer for the uninsured. As health care costs have dramatically increased over the last two decades, the role of government has become progressively more important to individuals, providers, and employers. a) Government should provide equal tax incentives for all purchasers of health care benefits. b) The principal sources of health care delivery should be non-governmental hospitals and health care providers. Government (both state and federal) should serve as a payer for services, rather than a provider of care, with accountability for spending tax dollars wisely. c) Government needs to balance the legitimate interests of patients and health care providers where malpractice may have occurred. Health care providers need legislation defining the scope of a provider s responsibility more narrowly than is presently true so excessive precautions will not be part of the provider s treatment routine. Government should also maintain appropriate limitations on consequential and punitive damages. d) The government should impose case-based guidelines that stipulate the amount of remuneration received by plaintiff lawyers. Disproportionate contingency fees for plaintiff lawyers should be discouraged. e) Government should develop an incentive for individuals to not spend dollars allocated for health 7
care rather than the current use it or lose it philosophy required by Section 125 of the Internal Revenue Code. Devices such as Medical Savings Accounts, Health Reimbursement arrangements, and Health Savings Accounts should be encouraged. f) The federal government should encourage experimentation by the states in the administration of government programs such as Medicare and Medicaid to develop models that will provide care at a more reasonable cost. g) Access to government funds for wellness and healthy lifestyle programs needs to be simplified because the bureaucratic process makes it difficult to obtain those funds. h) Government should pay the competitive price for the services it provides to the public, rather than seeking an arbitrary preferred rate, which necessitates the shifting of cost of services to others. i) Government should not grant preferred tax status or other privileges, to third party payers who design plans which provide benefits only to persons with the lowest health risks, thereby shifting the higher risks to other third party payers. j) Government should add administrative steps only when they add value to provisions of health care. Its role should be to simplify, not add costs. k) Government should cooperate within the community, in the collection of data the community can use to compare the utilization and outcomes relating to procedures and treatment. l) Government should not impede the collection and utilization of medical information in the absence of imminent harm to an individual. m) Government, at all levels, should not mandate participant benefits in employer sponsored plans. 5. Responsibilities of the Community Background The health of a community determines its quality of life. It is a major resource for social and economic development. The community plays an important role in health care delivery and can directly influence its people by enabling them to improve their health and well being. a) Community agencies should address adverse lifestyle practices or poor nutritional habits with 8
education and information campaigns, such as programs to improve diet, manage stress, encourage exercise, and reduce smoking and substance abuse, which will change the public s attitude. b) The community should recognize the responsibility of each individual for their own health care by the effective and efficient use of community resources to avoid over-utilization. c) The community should encourage the adoption of a unified, common, community-wide, electronic medical records, which would encourage prompt and easy transfer of patient data between providers and third-party payers. d) The community should encourage a de-identified shared medical claims and benefits information database, which would be available to providers, third-party payers, and, where permissible, to employers. e) The community should encourage and expect its health care professionals to use and report regional variations in health care utilization and outcomes compared to other communities. This information, similar to what was shown in the Dartmouth Study, can be used to identify opportunities for community-wide improvements. f) The community should encourage the adoption of evidence based clinical practice guidelines and practice standards for health care providers. g) The community should develop responsible board leadership for health care organizations. h) The community should develop expectations for cost restraints, non-duplication of services, and high-quality services. 6. Responsibilities of the Insurer and Third-Party Payer Background Given the complexity of the health care system and burgeoning costs to employers, HMOs and other insurers, must take a leadership position with respect to cost containment, clinical quality improvements (including safety), and service improvements. Through integrated data systems and other clinical software that combine medical, behavioral health and pharmacy claims, HMOs are in a unique position to lead in these large system improvements. a) Insurers and third-party payers should be innovative and initiate cost control actions with their customers through utilization of actuarial resources, experience, databases and other claims information. 9
b) Insurers and third-party payers should develop, make available, and market to individuals and employers, basic health care insurance programs actuarially sound and affordable. Third-party payers should develop affordable alternative plans to include catastrophic coverage or low deductible plans with a low annual benefit. c) The business and profit role of insurers and third-party payers obliges them to contribute solutions to the problem of the lack of basic coverage for many people. Solutions that only they can devise because of the vast resource of information and knowledge they have about the problems, as well as the influence they can exercise over the market place. d) Insurers and third-party payers should reflect factors such as diet, stress, exercise, and nonsmoking in the cost of health care plans offered to the public, in order to engage consumers in optimal health management. e) Insurers and third-party payers should be encouraged to develop a product which includes mental health coverage at the same level as other medical benefits for those who are seeking such coverage. f) Insurers and third-party payers should not utilize arbitrary limitations on the flow of medical information to patients and providers. g) Insurers and third-party payers should lead in the development and implementation of quality improvement of clinical quality and patient safety. 10
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